A survey of clinical empathy training at UK medical schools

Background The benefits of enhancing practitioner empathy include better patient outcomes and improved job satisfaction for practitioners. Evidence suggests empathy can be taught and empathy is listed as an outcome for graduates in the General Medical Council requirements. Despite this, empathy training is not mandatory on medical school curricula and the extent to which medical students are given empathy-specific training is unknown. Aim To conduct a survey of empathy training currently offered to medical students in UK medical schools. Methods An invitation to participate in an online survey was sent to all UK medical schools (n = 40). The survey was developed through a consultancy and pilot process to ensure validity and reliability. Questions explored what empathy-focused training is offered, and asked educators whether or not they believed that current provision of empathy training is sufficient. In parallel, medical school websites were searched to identify what information regarding empathy-focused training is described as being part of the degree course. Descriptive statistics were used to describe empathy training delivery from the results of the online materials survey and closed survey questions. Thematic analysis was used to explore free text comments. Results Response rate was 70% (28/40), with 28 medical schools included in the analysis. Twenty-six schools reported that their undergraduate curriculum included some form of empathy-focused training with variation in what, when and how this is delivered. Thematic analysis revealed two overarching themes with associated sub-themes: (i) empathy-focused training and development (considering where, when and how empathy training should be integrated); (ii) challenges presented by including empathy on the curriculum (considering the system, students and faculty). All schools agreed empathy training should be on the undergraduate curriculum. Conclusion This is the first nationwide survey of empathy-focused training at UK medical schools. While some form of empathy-focused training appears to be provided on the undergraduate curriculum at most UK medical schools, empathy is rarely specifically assessed. Most medical educators do not feel their school does enough to promote empathy and the majority would like to offer more. Supplementary Information The online version contains supplementary material available at 10.1186/s12909-022-03993-5.

in clinical empathy should be included on the undergraduate curriculum [8]. Empathy can be fostered in medical students and professionals through training [9][10][11] .
The extent to which empathy-specific training is offered in UK medical schools is unknown and there is no standard empathy training available. In parallel, there is evidence too that empathy may decline during medical school [12]. This survey of medical educators and medical school websites seeks to establish the degree to which empathy training is routinely included in medical education within UK medical schools.
There are many accepted definitions of empathy in the clinical setting [13,14]. In addition, there is overlap between clinical empathy and other related but different concepts, such as interpersonal and communication skills. We are following what appears to be an emerging consensus [5][6][7][8][9][10][11][12][13][14][15][16][17][18] that therapeutic empathy is the ability to understand the patient's perspective, to communicate this understanding, and to act on it in a helpful (therapeutic) way [19].
In this survey, we asked the research question: to what extent is empathy training currently included in the undergraduate medical curriculum across UK medical schools?

Aims and objectives
Our study aims are to: (1) determine whether empathy-focused training is offered to UK undergraduate medical students; (2) identify what empathy-focused training is offered to UK undergraduate medical students; (3) to explore medical educators perceptions of introducing empathy to the medical school curriculum.

Methods
Our study objectives are to: 1) conduct a survey of representatives of all UK undergraduate medical schools to determine whether and what empathy-focused training is offered as part of their curriculum and whether there is an appetite for more; 2) conduct a survey of all UK undergraduate medical school websites to determine what empathy-focused training is offered as part of their curriculum.
We recognise that many teaching activities, for example communication skills training, can develop empathy to some degree. To capture these activities that are related to empathy but not labelled as empathy, we define 'empathy-focused training' as any educational activity that has been developed with the primary outcome of fostering clinical empathy.

Study design
This is a cross-sectional study of UK medical schools and medical educators. The Consensus-Based Checklist for Reporting Survey Studies (CROSS) [20] has been adopted to report our findings. The survey protocol is registered with Open Science Framework [21].

Survey design
The lack of a standardised survey questionnaire that addressed the aims of this study led to the development of our own (see Additional file 1). The survey was generated on Jisc Online Survey software. Questions were based on a systematic search of studies and reviews exploring empathy training and curricula at medical schools, [9][10][11]22] and through a review of related studyspecific questionnaires of teaching (including communication skills (not explicitly empathy-focused)) at UK medical schools [23][24][25]. A series of closed questions plus some open-ended questions inviting free text responses were used. Questions fell in to four domains: (a) questions about the institution and role of respondent, (b) questions about empathy-focused training, (c) questions about the assessment of empathy and (d) questions about the respondents' opinions of empathy-focused training. Survey questions were put through a consultation process with a group of medical educators, clinicians and curriculum developers (n = 8) to ensure face validity and that questions were clear and unambiguous. The survey was piloted with senior medical educators from three different medical schools.

Sample characteristics
Medical education leads (MELs) at forty-one medical schools offering a standard entry and/or graduate entry accredited medical degree for national students were contacted through the Medical Schools Council to take part in this study.

Survey administration
MELs were sent a description of the study (see Additional file 2) with contact details for the primary investigator and a link to the survey platform, and asked to nominate a representative with knowledge of the curriculum content. A follow-up reminder was sent to medical schools who had not responded at 10 and 17 days. For medical schools who had not completed the survey following the second reminder, alternative contacts at the medical school were emailed to request participation.
In parallel, an online survey of UK medical school websites and official online materials (prospectuses/ course pages) was conducted by RW between 2 February 2022 and 7 March 2022. University and medical school websites, along with, where available, online prospectuses and programme specifications, were manually searched for written, audio and visual course and curricula information relating specifically to; the current provision of specific empathy-focused training; the current provision of communication/interpersonal skills training; empathy as a skill or attribute that is assessed for in relation to selection to medical school. In addition, the terms 'empathy' , 'empathic' , 'empathetic' and 'compassion' were searched for using the internal search engine on each university website with all results viewed to ensure that any information about empathy-focused training/teaching activities was captured. In addition, each university website was searched for the medical schools' 'programme specification' . If not found, a search using Google was run (using the name of the medical school and 'programme specification'). Where a programme specification was identified, this was searched to identify details relating to empathy-focused training and learning outcomes. The types of course offered by each medical school (standard entry, graduate entry, medicine with foundation or gateway year) was also recorded.

Data analysis
Responses from medical educators were anonymised and assigned a code. Descriptive statistics were used to summarise data collected from closed survey questions to help identify any meaningful trends. Thematic analysis, to allow for themes to emerge from the data rather than be driven by an existing framework, [26] was used to explore data collected from open survey questions. Themes were identified by RW using a Word document to organise data with supporting quotes identified for each theme. A second author (JH) reviewed themes and meanings, with any disagreement resolved through discussion. RW and JH discussed and selected quotes for inclusion within the main study.

Results
We sent surveys to MELs at 41 schools. One medical school declined to take part as they are a new medical school that had not yet completed their first year intake of students and we did not include it. Twenty-eight medical schools (70%) completed the survey. England, Scotland and Wales were all represented within the schools that responded. Results are summarised in Table 1.
Of the schools that responded, 14 (50%) offered only standard entry (undergraduate) medicine course, two (7%) offered only graduate entry medicine and 12 (43%) offered both. Eleven medical schools offered medicine with foundation or gateway year entry. Eleven (39%) reported that their curriculum is taught at another medical school. Of those completing the survey on behalf of their medical school, 24 (86%) described their role as being involved in both 'curriculum design and delivery' . One described their role as 'curriculum design' , and two reported their role as 'other' (and described their role as 'Professionalism Lead').
Eleven medical schools (27%) did not respond to requests to complete the survey. Of these, nine (82%) offered standard (undergraduate) medicine course, and two (18%) offered both standard entry and graduate entry medicine. Six schools (55%) offered medicine with foundation or gateway year entry. Schools who did not respond were located across England, Scotland and Northern Ireland.

Main findings
To reflect our study aims, findings are presented under three main headings (see below).
• Whether empathy-focused training is included on the medical school curriculum. • What empathy-training is included on the medical school curriculum.
• If and how empathy-focused training is evaluated, or student empathy assessed.
• Whether there is a requirement for more empathyfocused training to be included on the medical school curriculum.

Empathy-focused training
Twenty-six (93%) medical schools reported that their curriculum included some form of formal empathyfocused training or educational activity designed to foster empathy. Of these, eight (29%) stated there was a dedicated empathy-focused programme or module as well as empathy-focused training activities being integrated into other courses or modules. Sixteen (57%) reported empathy-focused training activities were integrated into other courses or modules. Two medical school stated  Are any empathy-specific tools used to measure student empathy? (select all that apply) Is the assessment of empathy, or a student's ability to empathise considered in the admissions to medical school process? there was an empathy-focused programme or module only. One school stated there was no formal empathyfocused training and one was unsure. All of the schools that reported some form of empathy-focused training was offered to students indicated this was done so as part of the mandatory curriculum. Specific empathy-focused training was reported to happen most frequently in the first and second year of medical school. Twenty-one (75%) medical schools reported empathy-focused training as mandatory, whilst 5 (18%) reported it was included on mandatory and optional curriculums.
There was a wide variety in the way empathy training is reported to be delivered by schools. Of those who report that empathy training is offered, most report this to be through lectures (35%), small group work (93%) and clinical experiences (64%). Clinical academics (82%), NHS clinicians (75%) and clinical teaching fellows (61%) were most frequently reported to delivery empathy-focused training. Eleven medical schools (39%) reported that patients assist with the delivery of empathy training.
Twelve medical schools (43%) reported some form of training or development for faculty on clinical empathy was delivered to those responsible for teaching this to students. Eight schools (29%) were unsure if any training was provided and eight (29%) reported no training was offered. Of the responders who provided examples of training given, these included: 'clinical tutor training days' with empathy being discussed as part of the whole communication delivery; tutor training on the 'model of empathy'; training workshops on 'effective consulting'; an e-learning package on clinical empathy as part of initial training to work with students.
Nineteen schools (68%) reported their curriculum delivered additional teaching that they felt fitted our definition of empathy, but was labelled as something other than empathy-focused training. Examples included communication skills training; patient experiences; patientcentred care; professionalism.

Evaluation and assessment
Of the 26 (93%) medical schools that reported their curriculum did include some form of formal empathyfocused training, 18 (64%) reported that training was evaluated and that student feedback on training was sought. Seventeen (61%) reported specific empathyfocused intended learning outcomes (ILOs) had been developed associated with training.
Twenty-two (79%) of schools reported student empathy is assessed at some point during the degree programme, with the most (86%) stating assessment was through Observed Structured Clinical Examinations (OSCEs) and/or reflective practice (54%). Only one (4%) medical school reported the use of empathy-specific tools to measure empathy (the Jefferson Scale of Empathy -Student Version). One school reported that 'empathy mapping' was used to specifically assess empathy and one reported the Generic Consultation Skills (GeCoS) tool was used.
Nineteen medical schools (69%) stated a prospective medical student's ability to empathise was assessed during the admissions process. Of these, five (18%) provided examples of how empathy was assessed, with all five stating through Multiple Mini Interviews or role-play scenarios. Eight schools (29%) reported they were unsure of, or unable to comment on admissions processes.

Future development
Of the schools taking part in the survey, 96% felt clinical empathy should be taught at medical school. Seven (25%) participants felt their medical school does enough to foster empathy in students, however, twenty-three schools (82%) reported they would like to see more empathyfocused training on the undergraduate curriculum.

Thematic analysis
Responders were asked to: • Describe in their own words what empathy-focused training their medical school provided. • Describe whether their curriculum included teaching that could be considered to fit our definition of empathy [19] but labelled as something else. • Give their opinion on how clinical empathy could be taught or how teaching could be improve.
Participant responses fell into two overarching themes: empathy-focused training and development, with subthemes around where on the curriculum training is or should be included and how it is (or is assumed to be) integrated into other activities; and challenges presented in putting empathy on the curriculum (related to the system, the students or the faculty). A summary of themes and supporting quotes is provided in Table 2.

Empathy-focused training and development
MELs described how clinical empathy is taught through their curriculum. They describe varying levels of integration, from specific, bespoke interventions that sit separately from other activities, to activities with the primary aim of fostering empathy, to an assumption that empathy training is covered somewhere in the curriculum.
(i) Dedicated empathy-focused training and development.

Theme Quotes
Empathy is intrinsically taught through other activities I think it is very difficult to untangle whether the primary aim of a teaching session is to improve empathy -it is taught with other skill and where the emphasis lies depend on who is teaching. (MEL 9) so I would say we have dedicated training on wellbeing (which helps awareness of emotional labour of care, suffering and compassion), self-awareness (bias, reaction to situations and triggers, choosing response rather than reaction), trauma-aware care, and compassion-all of which contribute to empathy, but we don't specifically badge it as 'empathy training' (MEL 7) Communication skills teaching for system focused patient consultation and simulation of the acutely ill patient (MEL 11) There is a mindfulness programme during year 1. (MEL 3) We have a large cohort of Patients as Educators (in excess of 800) and they work with students throughout the 5 years (teaching and assessment) to understand the impact of illness. ( MELs discussed standalone empathy training that aimed to be patient-centred, encouraging students to focus on 'understanding the patients' perspective' , identifying the 'therapeutic nature' of consultations and becoming more 'attuned to their patients' . "The course "Developing Clinical Empathy" aims to help students develop an empathic practice that is personal and attuned to their patients. " (MEL 1) "There is a 1 hour online workbook that outlines why we should be empathetic to our patients…" (MEL 5) "Specific simulated patient encounters to deal with empathy" (MEL 16) (ii) Empathy training is integrated into other activities.
MELS stated that specific learning on empathy was integrated into other teaching activities, including communication skills, clinical placements and through specific scenario training such as in 'breaking bad news' .
"we discuss empathy and the use of empathetic statements routinely as part of our small group communication skills training. " (MEL 20) "empathic communication is integrated into pretty much all of the communication training, which occurs throughout the course. " (MEL 14) (iii) Empathy training is intrinsically taught through other activities.
A number of MELS described how they felt empathy was nurtured in students indirectly, through a number of other teaching and learning activities, without the need to necessarily focus on empathy as a specific skill in itself.
"I think it is very difficult to untangle whether the primary aim of a teaching session is to improve empathy -it is taught with other skills and where the emphasis lies depend on who is teaching. " (MEL 9) "we don't label anything specifically as 'empathy training' but we include the above [definition of empathy as used by survey] which contribute to this construct" (MEL 7) (iv) Assumption that empathy training is included elsewhere in the curriculum.
There was a belief from some MELs that empathy development in students was automatically incorporated into other curricular activities. Some were unclear however if this did indeed happen consistently or to what extent it occurred.
"All clinical placements should have inbuilt opportunities to further develop clinical empathy, but I am unsure how much this occurs. " (MEL 6) "We don't specifically say "empathy-based training" as we are not teaching students to 'learn to sound empathic' as an isolated skill, or thinking about 'one item' . It is -hopefully -integrated. " (MEL 6) "I suspect this is provided on an ad hoc basis in a variety of specialties. It is informally being delivered throughout the curriculum. " (MEL 17)

Challenges presented in putting empathy on the curriculum
MELs commented frequently on the challenges they found from their experience, or could foresee in attempting to further establish empathy-focused training on the undergraduate curriculum. Three sub-themes were identified here, with challenges related to the system, students or staff.
Lack of time and resources, large cohorts of students, poor role models and lack of control over clinical environments were all cited as potential problems when trying to implement training for students in empathy. MELs commented on student engagement with and attitude to training and the difficulties this presents. In addition, the need for 'specialist support' for students who have 'particular challenges relating to others' was raised as a concern.
"Whilst things have improved for empathy/communication, there are still a reasonable proportion of students who perceive these areas as soft and fluffy, and not as important as the hard science. " (MEL 5) (iii) Staff and faculty engagement, experience or attitude.
Attitudes to empathy-focused training and how best to implement it varied with some MELs rejecting the idea that empathy can be taught. Concerns were raised that training and assessment would drive students away from a 'values based approach' with students more concerned about appearing empathic to pass exams.

Survey of online materials
All 41 medical schools' online materials provided information about undergraduate teaching and the course curriculum for their degree programme(s). Information obtained from websites/online prospectuses was summarised (see Additional file 3). The majority (83%) of medical schools described no specific empathy-focused teaching/learning activities explicitly aimed at enhancing empathy in their degree course. Seven medical schools described some form of teaching/learning that was either labelled as empathy-focused, aimed at fostering empathy or described as an activity that could be considered to fit with our definition of empathy [19]. For example, one medical school described a teaching activity as "giving our students invaluable insight into the experience of people with a medical condition or disability, and their carers". There was variation in the descriptions given, with some online materials mentioning empathy as an outcome or aim of teaching, and others giving more specific detail about what/when/where empathy training is provided. We accept that some teaching/learning activities that could be considered to foster empathy may be described without explicitly discussing empathy. Twentysix medical schools (63%) explicitly referenced empathy as part of the selection process to medical school, with the majority referring to empathy being assessed during Multiple Mini Interviews.
Of the 28 schools that responded to our survey, 23 (82%) websites described no specific empathy-focused teaching/learning activities. Eighteen (64%) explicitly referenced empathy as part of the selection process. A review of the websites of the 11 schools that did not respond to the survey identified that nine (82%) described no specific empathy-focused teaching/learning activities. Five (45%) explicitly referenced empathy as part of the selection process to medical school.

Summary and evaluation of results
This study is the first of its kind to explore the current provision of empathy-focused training at UK medical schools through a survey of medical educators and of medical school websites. The results of this survey provide valuable insight into the priority that clinical empathy training is currently given at medical schools across the UK. Our main finding was that while most respondents report that their undergraduate curriculum includes empathy training, empathy is rarely assessed, and there is an appetite for more.
Our results highlight a number of discrepancies between different aspects of the quantitative results, and between the quantitative and qualitative results.
Firstly, whilst the majority of medical schools report they provide some form of empathy-focused training to students, most do not provide dedicated empathyfocused training, programmes or modules. Almost two thirds of medical schools believed that their curriculum provides empathy training labelled as something else (with examples including communication skills, consulting skills, medical humanities, mindfulness, ethics and professionalism). Given the general lack of consensus in defining empathy in the clinical setting, it is unsurprising that there should be confusion over what empathy-specific training is and what it is not. Our thematic analysis supports quantitative findings in identifying that there is some confusion or misunderstanding around if, when and where empathy-focused training is delivered in the curriculum. For example, some educators assume empathy training is integrated throughout the curriculum or intrinsically taught through other activities, though some noted it cannot be assumed that empathy training is implied in the curriculum. Our findings support those of a recent systematic review [27] which found that interventions aiming to improve medical students' interpersonal communication skills, targeting skills associated with empathy but not specifically empathy-focused, do not always improve student empathy. In addition, evidence supports the need for empathy-focused training to be delivered as a formal, sustainable programme integrated into the curriculum [8,28] if it is to be impactful.
Secondly, whilst almost all medical schools reported that they do include some form of empathy-focused training, a third of these did not report or were unsure if ILOs are associated with empathy-focused training.
Relatedly, approximately a third reported either that there is no formal evaluation of empathy-focused training or uncertainty regarding whether there is formal assessment. Two-thirds of medical schools reported that there is either no form of training provided to faculty around how to teach clinical empathy or that they are unsure.
Thirdly, whilst the majority of medical schools (80%) reported that students' ability to empathise is assessed (formally or informally, for example through OSCEs or portfolio activities), only one medical school reports the use of a validated empathy-specific measurement tool. Research identifies that in order to move empathy from a nebulous idea to a tangible skill, students must be evaluated and empathy assessed [29]. Whilst there is currently little research into the role of student assessment on the formation and development of empathy at medical school, evidence from the wider field of medical education suggests formal assessment and evaluation can support students in achieving the desired outcomes [30].
Lastly, most wish to see more training offered. This tentatively implies that they believe that current empathy training is lacking.
Our website search identified that with a small number of exceptions, most medical school websites do not describe empathy-focused training explicitly as part of the content of their undergraduate medical degree.

Strengths and limitations
To the best of our knowledge, this is the first study to explore the current provision of empathy-focused training at UK Medical Schools. A strength of the study is our high response rate. There are also several limitations to this study. Our focus has been on UK medical schools, which limits the generalisability of our findings. Investigation as to whether empathy training is included in undergraduate curricula more internationally may provide useful insights into how different countries support their students in fostering an empathic approach to practice, and the importance they give it. Another limitation is that our study relies on the concept of empathy, which remains poorly defined. The thematic analysis identified that participants felt empathy-focused training is provided indirectly through other teaching and learning activities, such as communication skills. A final limitation is our website search. This was performed by one person and relied on search terms, and therefore we may have missed mentions of empathy. In addition, the website search limitations correlates to other limitations, especially that empathy could be described on the website but called something else (such as communication skills). By describing the findings of a the website search by schools who did and did not respond to our survey, we sought to identify whether a respondent bias was present. There was little difference between the websites of schools who responded and those who did not in terms of whether empathy-focused training is explicitly discussed on the school website (82% of schools who did not respond and 82% of schools who did respond to the survey did not explicitly describe empathy-focused training/ learning activities). A minor difference from the websites of responders and non-responders was that more of the schools that responded referenced empathy as part of the selection process (64% versus 45%). We therefore cannot rule out that non-responding schools could put less focus on the role of empathy training in medical school. Of note, our high response rate reduces the potential impact of responder bias.

Implications for research and practice
Medical educators have clearly expressed a strong appetite for more empathy training in medical schools. To achieve this, further research is needed to clarify the definition of empathy in the healthcare setting. This could then support the identification of the most appropriate pedagogical approaches or educational tools to nurture therapeutic empathy. In addition, whilst it is unlikely that a single 'one-size-fits-all' package of empathy training would be beneficial, evidence-based strategies will guide educators in making the most of often limited space on the curriculum.

Conclusion
Our survey identifies that empathy-focused training is included to some extent on the medical school curricula of most UK medical schools. There is confusion around how therapeutic empathy and empathy-focused training differs from other related, but different concepts (such as compassion or communication skills). Empathy-focused